2. Kevin T. Rich, MD, FAAFP | Chief Medical Officer| Family Medicine Residency of Idaho, Boise, Idaho | Associate Professor of Family Medicine | University of Washington SOM | Assistant Clinical Professor | Idaho State University | Past President | Idaho Academy of Family Physicians | Chair, Practice Transformation Committee| Idaho Medical Home Collaborative Chair, Regional Healthcare Collaborative | Idaho Healthcare Coalition Patient Centered Medical Home 28 th Annual Idaho Conference on Health Care 8 th Annual Thomas Geriatric Health Symposium October 2, 2015 PCMH in Idaho – What it is and What it will become

3. I N A N A VERAGE M ONTH : White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025.

6. P RIMARY C ARE = Q UALITY

7. P RIMARY C ARE = L OWER C OST

8. I NCREASED G ENERALIST C ARE = H IGHER Q UALITY

9. I NCREASED G ENERALIST C ARE = L OWER C OSTS

10. I NCREASED S PECIALTY C ARE = W ORSE Q UALITY

11. I NCREASED S PECIALTY C ARE = H IGHER C OST

12. P ATIENT C ENTERED M EDICAL H OME  Place  Process P ATIENT C ENTERED M EDICAL H OME N EIGHBORHOOD

13. R ATIONALE FOR THE B ENEFITS OF P RIMARY C ARE FOR H EALTH  Greater Access to Needed Services  Better Quality of Care  A Greater Focus on Prevention  Early Management of Health Problems  Cumulative Effect of Primary Care to more Appropriate Care  Reducing Unnecessary and Potentially Harmful Specialist Care Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

14. P ATIENT C ENTERED M EDICAL H OME  Place  Process

15. PCMH: W HAT DOES IT LOOK LIKE IN PRACTICE ?  “Integrated and coordinated care with the patient at the center”  “A continuous relationship with a personal physician/physician team occurs, coordinating care for both wellness and illness.”  Fundamental principles:  Improved access to care  Comprehensive care  Whole person orientation  Care management  Continuity of care  Team approach to care  Culture of quality and safety  Integration of health information technology to improve access to care, quality of care and patient safety.

16. PCMH D EFINITIONS /T ERMINOLOGY  Standards  NCQA  URAC  TransforMed  Change Concepts  McColl Institute  SNMHI/Qualis

17. PCMH S TANDARDS  TransforMed  Access to Care and Information  Practice Services  Care Management  Continuity of Care Services  Practice-Based Care Team  Quality and Safety  Health Information Technology  Practice Management  NCQA  Enhance Access and Continuity  Identify and Manage Patient Populations  Plan and Manage Care  Provide Self-Care Support and Community Resources  Track and Coordinate Care  Measure and Improve Performance

18. C HANGE C ONCEPTS  Engaged Leadership  Quality Improvement Strategy  Empanelment (linking each patient with a provider)  Continuous, Team-Based Healing Relationships  Patient-Centered Interactions  Organized, Evidence-Based Care  Enhanced Access  Care Coordination

19. M S. G  Ms. G is a 48 yo single mother of three teenagers who does domestic work.  She is underinsured and receives her care at a public hospital clinic.  BMI of 37, poorly controlled diabetes, elevated blood pressure and painful osteoarthritis of her knees.  Chronically depressed and has required opioids to control her knee pain. She frequently misses her doctor appointments, and the clinic suspects that she is not taking her medications (including opioids) as prescribed. Her depression seems to be unresponsive to meds, and her symptoms are making it harder for her to work.  Ms. G became increasingly fatigued and dyspneic, and was admitted in CHF.

20. M S. G’ S M EDICAL C ARE PER C HANGE C ONCEPT Enhanced Leadership Leadership preoccupied with financial status *Ensure that the PCMH transformation effort has the time and resources needed to be successful. *Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. Quality Improvement Strategy Performance measurement limited to required reports. Occasional QI projects. *Ensure that the PCMH transformation effort has the time and resources needed to be successful. *Ensure that providers and other care team members have protected time to conduct activities beyond direct patient care that are consistent with the medical home model. *Ensure that patients/family, providers, and care team members are involved in quality improvement activities Empanelment No effort to link patients with primary care teams. Despite poor disease control and missed appointments, practice has never tired to initiate a visit. *Assign all pts’. a panel *Use panel data and registries to proactively contact and track patients

21. Continuity and Team-Based Care She sees whoever has an appointment available that day. MD’s have no defined team. *Link patients to a provider and care team that are accountable to the care of pts. Define roles and distribute tasks among care team members Organized Evidence-Based Care Care delivered in brief, reactive visits. Her no-shows make it hard to titrate meds. No staff available to provide more intensive follow-up. *Identify high risk groups and ensure they get care needed; *Planned care visits; *Evidence-based POC reminders AccessNo evening or weekend appointments make it difficult for her to work and keep appointments. *24/7 access via phone, email, *Open access scheduling

22. CoordinationThe clinic was unaware that she went to the ED with symptoms of CHF and was admitted. She was readmitted 3 weeks after discharge having had no outpatient care. *Follow up with patients within a few days of an emergency room visit or hospital discharge. *Communicate test results and care plans *Link pts. with community resources and communicate with referrals Patient-Centered InteractionsNo trained self-management support. She often doesn’t understand what the MD’s tell her to do. *Post visit f/u- print or email care visit summaries *Care plans

23. T RANSFORMATION  What is it?  Practice Redesign  Looking at a different way of delivering care o “Integrated and coordinated care with the patient at the center” o “A continuous relationship with a personal physician/physician team occurs, coordinating care for both wellness and illness.”  Fundamental principles:  Improved access to care  Comprehensive care  Whole person orientation  Care management  Continuity of care  Team approach to care  Culture of quality and safety  Integration of health information technology to improve access to care, quality of care and patient safety.

24. T HE PCMH D ATA -T O -D ATE  Excellent ROI  Geisinger Health Systems, Group Health Cooperative, MultiCare, Dean Health System, CCNC, IHC  Quality of Care, Patient Experiences, Care Coordination, and Patient Access all Improve  Decrease ER Utilization 15-50% (Avg. 30%)  Decrease Hospitalization 10-40% (Avg. 19%)  Decrease Cost/Patient $835-$1,750/Year  Increase Patient Satisfaction and Decrease Physician Burnout

25. T HE F UTURE OF THE M EDICAL H OME IN I DAHO

26. W HAT IS THE SHIP? The State Healthcare Innovation Plan (SHIP) is a statewide plan to redesign our healthcare delivery system, evolving from a volume-driven, fee for service system to a outcome-based system that achieves the triple aim of improved health, improved healthcare and lower costs for all Idahoans.

27. I DAHO SHIP M ODEL E LEMENTS  Strong Primary Care System  Patient Centered Medical Homes (PCMH) – Foundational  Medical Neighborhood (Hospitals, Subspecialists, Others)  Regional Cooperatives (RC) Support Local Primary Care Providers and Medical Neighborhood  Statewide Idaho Healthcare Coalition (IHC)

28. I DAHO SHIP M ODEL E LEMENTS  Health Information is Linked Electronically by EHR and HIT  Data Analytics  Payment Systems are Aligned Across Major Payers  Patient Engagement/Accountability  Transforms Public Health to Population Health

29. Regional Collaborative Patient Centered Medical Home (PCMH) Patient Centered Medical Home Neighborhood Idaho Healthcare Coalition (IHC) / SHIP

30. I DAHO H EALTHCARE C OALITION (IHC) M ODEL T ESTING G RANT  $61M Grant (CMMI)  Notified November 5, 2014 – $40M  Four Years  Achieve Triple Aim: Better Health; Better Healthcare, Lower Costs  Projected Savings $89M/Three Years  ROI (197%) over Five Years

31. IHC M ODEL T ESTING G OALS  180 Primary Care Practices (PCMH’s) over Three Years (900 PCP’s); 1.3M People (80%)  EHR/HIE Integration (PCMH / Neighborhood)  Build Seven Regional Collaboratives  75 Virtual PCMH’s (>550 CHW’s/CHEMS) / Telehealth  Data Analysis – Collecting, Analyzing, Reporting  Align Payment Mechanisms

32. I DAHO H EALTHCARE C OALITION (SHIP) S UMMARY  Vehicle and Model for Healthcare Transformation for Idaho  Built on Foundation of Primary Care and the Patient Centered Medical Home (PMCH)  Integrates and Coordinates the PCMH with Secondary Providers, Hospitals, and Other Members of Healthcare Team  Connects Public Health to Population Health Quality Metrics  Integrates Clinical and Claims Data  Aligns Payment Systems with Access and Outcomes  Transforms Health Care in Idaho  Triple Aim

33. I NTEGRATION  EMR  PCMH  PCMH Neighborhood  Hospitals  ACO

34. S YMPHONY OF C ARE

35. T HE I MPORTANCE OF FM/PC AND THE PCMH TO I DAHO ’ S T RANSFORMING H EALTH C ARE S YSTEM  The Backbone  First Line of Care  Leverages Relationships, Continuity, Comprehensiveness  Focuses on Health  Integrates and Coordinates  Bridge to Other parts of the Health Care System when Needed  This is the Future of Health Care in Idaho

36. THE PCMH IN I DAHO T ODAY AND T OMORROW T ODAY  Concept – Adolescence  Implementation – Childhood  Payment – Infancy  Potential – Value-Add T OMORROW  Adulthood  Young Adulthood  Tremendous Value-Add

37. Q UESTIONS